2
Medicaid Waivers were developed to encourage people with disabilities and the elderly to access services in their homes and communities.

3
Virginia’s waiver programs for the elderly and disabled are expensive but still less costly than compatible institution care. Virginia’s waiver programs for the elderly and disabled are expensive but still less costly than compatible institution care. The elderly and disabled represent The elderly and disabled represent 30% of Medicaid program recipients. 30% of Medicaid program recipients.

6
Elderly or Disabled with Consumer Direction Waiver This waiver is constructed to allow persons to remain in the community that meet nursing facility level of care. This waiver is constructed to allow persons to remain in the community that meet nursing facility level of care. Current enrollment 12,187 Current enrollment 12,187 No waiting list No waiting list

7
Eligibility This waiver serves the elderly and persons of all ages with disabilities. The individual may receive this service through a service provider or though consumer direction. This waiver serves the elderly and persons of all ages with disabilities. The individual may receive this service through a service provider or though consumer direction. An individual can remain on the waiting list for another waiver while being served by the EDCD Waiver. An individual can remain on the waiting list for another waiver while being served by the EDCD Waiver.

9
Criteria Qualify for Medicaid (individual) Qualify for Medicaid (individual) Meet long term care criteria according to Uniform Assessment Instrument (UAI) Meet long term care criteria according to Uniform Assessment Instrument (UAI) Pre-Admission Screening Criteria: –Functional capacity (the degree of assistance an individual requires to complete activities of daily living); and –Medical or nursing needs –Risk of nursing facility placement

10
Pre-admission Screening A recipient may qualify for nursing facility level of care or placement in a waiver by meeting one of the following criteria: A recipient may qualify for nursing facility level of care or placement in a waiver by meeting one of the following criteria: -Dependent in 2 to 4 ADL’s, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in medication administration; or -Dependent in 2 to 4 ADL’s, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in medication administration; or -Dependent in 5 to 7 ADL’s and dependent in mobility; or -Dependent in 5 to 7 ADL’s and dependent in mobility; or -Dependent in 2 to 7 ADL’s plus dependent in behavior and orientation; AND -Dependent in 2 to 7 ADL’s plus dependent in behavior and orientation; AND -Have medical nursing needs -Have medical nursing needs

12
Getting Started Request for screening, contact either the local Department of Social Services or the local Health Department Request for screening, contact either the local Department of Social Services or the local Health Department Schedule visit with nurse Schedule visit with nurse Completed Medicaid application (child’s information only!) Completed Medicaid application (child’s information only!) Meet with Home Health Care Agency Meet with Home Health Care Agency

13
Technology Assisted Waiver (Tech) No age limit to eligibility No age limit to eligibility No waiting list No waiting list Currently serving (2007) 295 individuals. Currently serving (2007) 295 individuals.

14
Eligibility Serves individuals who need a medical devise to compensate for the loss of a vital body function and requires substantial and ongoing skilled nursing care to remain safely in their homes. Serves individuals who need a medical devise to compensate for the loss of a vital body function and requires substantial and ongoing skilled nursing care to remain safely in their homes. Recipients with private insurance which provides PDN as a benefit must exhaust this service prior to waiver service initiation Recipients with private insurance which provides PDN as a benefit must exhaust this service prior to waiver service initiation

16
Criteria Doctor must certify need for care; and need substantial and ongoing skilled nursing care; and Doctor must certify need for care; and need substantial and ongoing skilled nursing care; and Care must be cost effective; and Care must be cost effective; and Primary caregiver must be trained and accept responsibility for 8 hours or more per day Primary caregiver must be trained and accept responsibility for 8 hours or more per day

17
Criteria (younger than 21) Children must depend part of the day on a vent; or require prolonged intravenous nutrition, drugs or peritoneal dialysis; or have a daily dependency on other devise-based respiratory or nutritional support including tracheotomy tube care, oxygen support, or tube feeding; and Children must depend part of the day on a vent; or require prolonged intravenous nutrition, drugs or peritoneal dialysis; or have a daily dependency on other devise-based respiratory or nutritional support including tracheotomy tube care, oxygen support, or tube feeding; and Individuals who have been determined to need substantial and ongoing nursing care as indicated by a score of a minimum of 50 points on the objective scoring criteria Individuals who have been determined to need substantial and ongoing nursing care as indicated by a score of a minimum of 50 points on the objective scoring criteria

18
Screening Process DMAS receives a referral from community resources, family, other parties DMAS receives a referral from community resources, family, other parties DMAS completes a Scoring Tool to determine if the individual meets the specialized care criteria for the waiver DMAS completes a Scoring Tool to determine if the individual meets the specialized care criteria for the waiver If the criteria is met DMAS conducts a home assessment. If the criteria is met DMAS conducts a home assessment. DMAS works with the primary caregiver, referral source to secure appropriate nursing care for the individual in the home DMAS works with the primary caregiver, referral source to secure appropriate nursing care for the individual in the home DMAS authorizes needed services for the provider agency upon the start of care DMAS authorizes needed services for the provider agency upon the start of care

19
Individual and Family Developmental Disabilities Support Waiver (DD) DMAS is the administrator of the waiver DMAS is the administrator of the waiver Recipients served FY07 594, and 591 are waiting. Recipients served FY07 594, and 591 are waiting. Can be placed on the waiting list at age 5 years 8 months Can be placed on the waiting list at age 5 years 8 months

20
Eligibility Home and community-based care services that enables the individual six years of age or over to remain at home rather than being placed in an Intermediate Care Facility (ICF/MR)

22
Criteria Must be 6 years of age and over and meet the related conditions criteria, including autism; and Must be 6 years of age and over and meet the related conditions criteria, including autism; and Individual must not have a diagnosis of Mental Retardation. Individual must not have a diagnosis of Mental Retardation. Meet the level of care for admission to an ICF/MR. The individual must meet 2 out of 7 levels of functioning. Meet the level of care for admission to an ICF/MR. The individual must meet 2 out of 7 levels of functioning.

23
Screening The Virginia Department of Health Child Development Clinics will screen individuals with the Level of Functioning (LOF) Survey which is the assessment instrument used to determine eligibility to for an ICF/MR The Virginia Department of Health Child Development Clinics will screen individuals with the Level of Functioning (LOF) Survey which is the assessment instrument used to determine eligibility to for an ICF/MR You can download a copy of the “Request for Screening” from Compete the form and fax or mail it to the CDC. The psychological assessment is a requirement of the screening determination. You can download a copy of the “Request for Screening” from Compete the form and fax or mail it to the CDC. The psychological assessment is a requirement of the screening determination.www.dmas.virginia.gov

24
Transitioning from MR to DD Waiver Annually each child receiving MR Waiver services who will be 6 years of age the following year can be up for consideration for transfer to the DD Waiver. Annually each child receiving MR Waiver services who will be 6 years of age the following year can be up for consideration for transfer to the DD Waiver. If the child meets DD Waiver eligibility the child can transition to the DD Waiver. If the child meets DD Waiver eligibility the child can transition to the DD Waiver.

26
Eligibility Individuals must have an evaluation that reflects their current level of intellectual and adaptive functioning. Individuals must have an evaluation that reflects their current level of intellectual and adaptive functioning. Six and over – a psychological evaluation with a diagnosis of mental retardation. Six and over – a psychological evaluation with a diagnosis of mental retardation. Six and under – either a psychological or standardized developmental evaluation that states the child has a diagnosis of mental retardation or is at developmental risk. Six and under – either a psychological or standardized developmental evaluation that states the child has a diagnosis of mental retardation or is at developmental risk.

28
Criteria All individuals receiving MR Waiver services must meet the ICF-MR level of care. All individuals receiving MR Waiver services must meet the ICF-MR level of care. Case Manager completes a “Level of Functioning Survey.” The individual needs to have significant needs in two or more of the survey’s seven categories. Case Manager completes a “Level of Functioning Survey.” The individual needs to have significant needs in two or more of the survey’s seven categories.

32
Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Medicaid’s program for children up to age 21 with a preventative treatment approach Medicaid’s program for children up to age 21 with a preventative treatment approach

33
Services Screening/Well Child check-ups, lead testing and immunizations Screening/Well Child check-ups, lead testing and immunizations Treatment services to correct a medical condition, make it better, or prevent the child’s health status from worsening Treatment services to correct a medical condition, make it better, or prevent the child’s health status from worsening

34
Specialized Services: The following services are covered only under EPSDT The following services are covered only under EPSDT All require pre authorization at DMAS All require pre authorization at DMAS -Specialized Medical Treatment -Hearing Aids -Specialized and Substance Abuse Residential Treatment -Personal Care (ADL dependency in 3 areas) -Private Duty Nursing

35
Medical Necessity The medical justification for a service must accompany the request for EPSDT treatment services The medical justification for a service must accompany the request for EPSDT treatment services -Services not covered Respite Environmental Modifications VocationalEducational

36
Health Insurance Premium Payment Program If an individual receiving waiver services has private health insurance, Medicaid will be the individuals secondary insurance If an individual receiving waiver services has private health insurance, Medicaid will be the individuals secondary insurance DMAS may reimburse the individual for all or a portion of their monthly private health insurance premium DMAS may reimburse the individual for all or a portion of their monthly private health insurance premium

39
Examples Fails to take application for medical assistance Fails to take application for medical assistance Personal Care hours are reduced Personal Care hours are reduced EDCD Waiver is terminated for LOC EDCD Waiver is terminated for LOC

40
Steps Request an appeal or review Request an appeal or review (804) (804) Notify appeals division in writing Notify appeals division in writing Be specific about what you want Be specific about what you want -Results in a hearing -Decision made